Prevalence of the Usage of Smokeless Tobacco in Patients Presenting With Stroke in a Tertiary Care Hospital.

Background Stroke is one of the leading causes of disability, long-term morbidity, and mortality. The key modifiable risk factors for stroke are largely driven by demographic changes and various social adaptations. Smokeless tobacco consumption is high in developing countries with less awareness of its potential health risks. Aim This study was designed to determine the prevalence of usage of smokeless tobacco in patients presenting with stroke in a tertiary care hospital in Karachi. Methods This is a cross-sectional study conducted at the Department of Neurology of Dr. Ruth K. M. Pfau Civil Hospital in Karachi. A total of 192 patients were enrolled during the study period of six months, from September 2018 to March 2019. All consenting patients were recruited who presented with stroke and fulfilled the inclusion criteria. All patients were assessed by a trained neurologist. Results A total of 192 patients with stroke were included. There were 146 (76%) males and 46 (24%) females with a mean age of 53 ± 6.1 years. The highest percentage (39%) of cases was illiterate. A majority (64%) of patients presented belonged to a lower socioeconomic background. Out of 192 stroke patients, 131 (68.2%) consumed smokeless tobacco.  Conclusion The frequency of smokeless tobacco consumption was found to be high in stroke patients who require the attention of the physician on modifiable risk factors.

Association Between Hyperuricemia and Acute Ischemic Stroke in Patients at a Tertiary Care Hospital.

Introduction Stroke is the most debilitating of neurologic diseases. The rationale of the current study was to determine the association between hyperuricemia and ischemic stroke to establish a local perspective. Methods A total of 148 patients at a tertiary care hospital in Pakistan who fulfilled the inclusion criteria were enrolled in the study and then equally distributed into two study groups consisting of cases and controls (n = 74 in each group). In this study, there were 36 (48.6%) participants in the case group with hyperuricemia and ischemic stroke and 18 (24.3%) participants in the control group with hyperuricemia. The mean and standard deviations were computed for quantitative variables such as age, body mass index (BMI), and duration of stroke. Frequencies and percentages for the qualitative variables such as gender, hypertension, type 2 diabetes (T2D), dyslipidemia, smoking status, socioeconomic status, educational level, and hyperuricemia were calculated. The chi-square test was applied to compare both groups, with p ≤ 0.05 indicating significance. The odds ratio was also calculated to determine the association between case and control. Effect modifiers were controlled through stratification of age, gender, BMI, duration of stroke, hypertension, T2D, dyslipidemia, socioeconomic status, educational level, and smoking status to determine the effect of these on outcome variables. A post-stratification chi-square test was applied, with p ≤ 0.05 indicating statistical significance. Results In our study, stratification of hyperuricemia into cases and controls was performed for age, gender, T2D, hypertension, dyslipidemia, smoking status, socioeconomic status, and educational status. The maximum results were significant, with high strength of association between both groups. In the case group, the frequency of elevated uric acid was significantly higher than that of the control group. A comparison of hyperuricemia indicated p = 0.002, with an odds ratio of 2.95, which showed that elevated uric acid could be taken as a predictor of ischemic stroke. The uric acid level was significantly higher in men than in women. Additionally, hyperuricemia was associated with dyslipidemia. In patients with ischemic stroke, there was a significant association between serum uric acid level and T2D, hypertension, and smoking. Conclusions This study showed that the prevalence of hyperuricemia in patients with ischemic stroke was significantly higher as compared to the healthy population. Hyperuricemia can be considered as a risk factor for ischemic stroke because of its high prevalence in ischemic stroke patients. Our study explored the relationship between stroke and hyperuricemia and enabled increased understanding for caregivers so that effective management plans can be formulated for patients with ischemic stroke to prevent adverse outcomes.

Etiology and Types of Seizures in Patients Presenting to a Tertiary Care Hospital in Karachi: A Cross-Sectional Study.

Introduction Epilepsy is a burdensome disorder for affected individuals and community. There is limited data available on the epidemiological aspects of seizures in Pakistan and further research is necessary. We aimed to fill this gap by studying this information in epilepsy patients presenting to our neurology department. The purpose of this study is to evaluate the causes and types of seizures among the target population. Method This is a cross-sectional study conducted at the Department of Neurology, Dr. Ruth K.M. Pfau Civil Hospital Karachi. In this study we evaluated the causes and types of seizures among patients presenting to our department during the two-year study duration (January 2018-December 2019). Informed consent was taken. Detailed history was taken including features of seizure episodes, age at first seizure, family history and comorbid conditions. Relevant investigations were carried out. The data was compiled to deduce the relevant information using SPSS v20.0. T-test and Chi-square were used for analyzing the data. Results A total of 996 patients presented during the study duration. Primary seizures were found in 58% cases while secondary seizures were found in 42% cases. This distribution was more equal in children with 49.6% primary seizures and 50.4% secondary seizures; the gap widened in adults with 64.3% primary seizures and 35.7% secondary seizures. The most common cause of secondary seizures was neonatal encephalopathy which was present in 18.7% patients, followed by traumatic head injury in 18.2% patients. Central nervous system (CNS) infection was the cause in 17.9% patients, cerebral tumors in 14.1% patients, stroke in 11.5%, metabolic encephalopathy in 7.4%, febrile seizures in 6.5% and CNS malformations in 5.7% patients. The top three causes in children were neonatal encephalopathy (28.3%), CNS infections (19.3%) and febrile seizures (12.7%). Adults with secondary seizures were diagnosed most often with head trauma (25.2%), cerebral tumors (19.9%) and stroke (18.4%) as causative factors. The most common type of seizures was generalized onset tonic-clonic seizures which was found in 73.0% patients followed by focal to bilateral tonic-clonic seizures in 8.9% patients. Other types of seizures included focal aware seizures in 5.0%, mixed seizure types in 4.2%, focal impaired awareness seizures in 3.1%, absence seizures in 2.7%, myoclonic seizures in 2.0% and atonic seizures in 1.0% patients. Seizures in children were mostly generalized onset tonic-clonic seizures (75.4%), mixed seizure types (5.7%) and focal to bilateral tonic-clonic seizures (5.2%). In adults the three most common types corresponded to the overall result: generalized onset tonic-clonic seizures (71.2%), focal to bilateral tonic-clonic seizures (11.6%) and focal aware seizures (6.6%). Conclusion We found that the most common cause of seizures overall in our study population was primary seizures, though primary and secondary seizures were more evenly present in children. Among secondary causes neonatal encephalopathy stood out as the most common cause in children; head trauma was the predominant cause in adults. Most common type of seizures overall and in adults was generalized onset tonic-clonic seizures, followed by focal to bilateral tonic-clonic and focal aware seizure types. Pediatric patients presented most often with generalized onset tonic-clonic seizures, followed by mixed seizure types and focal to bilateral tonic-clonic seizures.

Cost of Investigating Neurological Disease: Experience of a Tertiary Care Center in Karachi, Pakistan.

INTRODUCTION:  Neurological disorders, structural or functional, are prevalent all over the world and are accompanied by physical and social morbidity. In this study, we aimed to calculate the cost of investigating neurological disorders and compare the costs incurred in a government hospital with that in a private hospital. MATERIALS AND METHODS:  This study was conducted at the Dr. Ruth KM Pfau Civil Hospital, Karachi, Pakistan. One hundred patients were enrolled in the study; 10 each investigated for epilepsy, cerebrovascular accidents (CVAs), headache, neuropathy, myopathy, cranial nerve palsies, movement disorders, demyelinating diseases, central nervous system (CNS) infections, and dementia. Receipts and records in the patients' medical history were used for the calculation of the cost of procedures, which was then compared with the costs of these investigations in a private hospital. A bottom-up costing approach was taken with individual costs being estimated and then being grouped to calculate the overall economic burden of the disorders. Data were analyzed using IBM SPSS version 23.0. One-way analysis of variance (ANOVA) was done to compare the mean cost (taken by the patient, covered by the government, total cost in the government hospital, and total cost in the private hospital) across diseases in government and private hospitals separately. Pearson correlation and scatter plot were also done to study the cost in private and public hospitals. p-values less than 0.05 were considered statistically significant. The margin of error in the study was 5%. RESULTS:  The mean age was 38.2 ± 20.5 years. Some 51% data were received from female samples. The mean income of samples was 13863.6 ± 9715.9 Pakistani Rupees (PKR) or 78.38 ± 58.29 United States Dollars (USD). The mean cost covered by government hospitals was 8866.0 ± 5071.0 PKR (53.19 ± 30.42 USD) per patient, whereas in government hospitals patients were charged on average 2662.9 ± 3774.7 PKR (16 ± 22.65 USD), while in private hospitals patients paid on average 29041.3 ± 12992.6 PKR (174.21 ± 78 USD). CONCLUSION:  The costs of investigations in private hospitals were approximately three times the costs in government hospitals. The maximum cost was generated by patients being investigated for demyelinating disorders. Investigations conducted in government-run hospitals are more cost effective and these institutions should receive increased funding to cater to the maximum number of patients.

Frequency of Autonomic Dysfunction in Patients of Guillain Barre Syndrome in a Tertiary Care Hospital.

Introduction Guillain-Barré syndrome (GBS) is defined as a syndrome manifesting as an acute inflammatory demyelinating polyradiculoneuropathy (AIDP) with coexistent weakness and absent or diminished reflexes clinically.Autonomic dysfunction (AD) or dysautonomia is a common finding in GBS. Autonomic dysfunction usually occurs in the acute phase of the illness but can also be seen in the recovery phase. The rationale of our study is to determine the frequency of autonomic dysfunction in patients of GBS admitted to the Neurology department of Civil Hospital, Karachi. Methods A total of 118 admitted patients at a tertiary care hospital in Pakistan who fulfilled the inclusion criteria were enrolled in the study after informed consent. The study was conducted for six months at the department of neurology, Civil Hospital, Karachi. Patients were assessed for autonomic dysfunction by recording blood pressures and pulse rate hourly (both lying and standing positions) by resident doctors. Urinary retention, diarrhea, and constipation were also recorded in a separate chart. All values entered in the pre-approved performa by researchers. The data was collected and analyzed on Statistical Package for Social Sciences (SPSS) version 18.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics included mean, standard deviation (SD) of continuous data, like age, duration of illness, motor weakness assessment by Medical Research Council (MRC) Scale, protein content in cerebrospinal fluid (CSF), pulse, and blood pressure at the time of presentation. Frequencies and percentages were calculated from the categorical data, like gender and patients with autonomic dysfunction (outcome variable). Effect modifiers were controlled by stratification of age, gender, duration of illness. Post-stratification chi-square test was applied with a p-value of ≤ 0.05 taken as significant. Results In our study, the average age of the patients was 39.90±9.91 years. Frequency of autonomic dysfunction among patients with GBS was 41.53% (49/118). The most frequent autonomic manifestations were constipation and diarrhea; 22% and 21.2% respectively. Additional manifestations included urinary retention (15.3%) and fluctuation of blood pressure and heart rate at 13.6% each.  Conclusion This study showed that the frequency of autonomic dysfunction among patients of Guillain Barre Syndrome was significant, consistent with previous studies. Our study explored the adverse outcomes of autonomic dysfunction in patients with GBS. This will help physicians increase their understanding of dysautonomia so that effective management plans can be formulated for patients with GBS to prevent adverse outcomes and hence provide better patient care.

Clinical Features Indicating the Need for Mechanical Ventilation in Patients with Guillain Barre Syndrome.

Background Guillain Barre Syndrome (GBS) is an immune-mediated inflammatory polyradiculoneuropathy. Respiratory failure is one of its recognized and most dreaded complications, requiring ventilatory assistance. Early recognition of distinct clinical predictors of mechanical ventilation may help in the better management of GBS patients in our setup. Objective To determine the clinical predictors indicating the need for mechanical ventilation in patients with Guillain Barre Syndrome and to compare the presenting features in patients who require mechanical ventilation and who do not. Method It was a prospective observational study. A total of 100 consecutive patients, over the period of one year, were included in this study. All patients were clinically examined for limb weakness, neck weakness, bulbar and facial nerve involvement, and followed up till seven days of hospitalization for whether the patient required mechanical ventilation or not. Results were recorded on a specifically designed proforma. Data were entered and analyzed using SPSS version 20.0 (IBM Corp., Armonk, NY, US). Results Out of 100 patients, 13% required mechanical ventilation. When clinical presentations were compared in patients who required mechanical ventilation and those who did not, a shorter interval between the onset of symptoms and the attainment of maximal disability, facial weakness, bulbar dysfunction, and neck weakness turned out to be significant factors (p-value<0.000). Conclusion According to these significant outcomes of our study, the course of patients with GBS leading to mechanical ventilation can be predicted on the basis of clinical presentations. So we can recommend that shorter time duration between symptom onset and peak disability, along with the presence of facial, bulbar, and neck weakness, should be taken as an indication of impending respiratory failure.